Failure to Provide Required Discharge Documentation and Appropriate Wheelchair for Resident Transfer
Penalty
Summary
The deficiency involves the facility’s repeated failure to provide complete and accurate documentation and personal records needed for a resident’s discharge and admission to a supportive living facility, as well as failure to obtain an appropriate wheelchair as ordered. The resident had a history of cerebral infarction with hemiplegia and hemiparesis affecting the right dominant side, foot drop, aphasia, expressive language disorder, major depressive disorder, pain, and unsteadiness on feet, and used a manual wheelchair for mobility. Physician orders documented that the resident was to be discharged to an assisted living facility and required a specific-sized wheelchair with defined features due to her cerebrovascular conditions, but there was no documentation in the medical record confirming that a new wheelchair had been ordered. On the day of discharge, the discharge summary noted that discharge education was performed, medications were sent with the resident, and that the resident took her own wheelchair and hemi-walker because they belonged to her. Subsequent observation at the supportive living facility showed the resident using a wheelchair in visible disrepair, including a cracked and broken plastic side panel near her hip, missing plastic on the armrest, and both armrests wrapped in thin elastic bandage tape. The resident reported that she had repeatedly requested a new wheelchair for months, including after becoming eligible for Medicare, and stated that the facility had told her at various times that a wheelchair was being ordered and later that it was not. She described the cushion as worn, tattered, and flat, and stated that the broken plastic poked and hurt her hip, requiring her to be extra careful. Interviews with the executive director and other staff at the supportive living facility revealed that they experienced numerous delays in obtaining the resident’s necessary documents from the skilled facility, including Social Security information, Medicare/Medicaid status, and accurate resident funds records. They reported that the skilled facility could not initially determine whether the resident was Medicaid or private pay, did not have an active Social Security card or award letter, and sent a commingled resident funds ledger with other residents’ information blacked out instead of a separate statement for this resident. These documentation issues, along with unresolved questions about the wheelchair order, caused months of delay in the resident’s admission to the supportive living facility despite her eligibility. The administrator of the skilled facility later confirmed that the delay in discharge was due to paperwork, identification records, and resident funds records not being submitted by the prior business office manager, and also confirmed that the facility did not purchase the resident’s wheelchair despite her repeated requests over the past year, resulting in her discharge with the broken wheelchair.
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